WHAT'S UP DOC? Mental status exam

Tuesday

Jan 23, 2018 at 6:10 PMJan 23, 2018 at 6:10 PM

Q: My doctor has never performed the mental status exam on me like was done for President Trump. What is this exam for?

A: The complete mental status exam (MSE) evaluates multiple things that can be used as a high-level screening exam to identify poor function of parts of the brain. It is not used to assess intelligence. Although it may be helpful in identifying patients at risk for certain psychiatric illnesses, it is not used to diagnose them or to rule them out. It’s main use is to screen for dementia, delirium and to help identify patients that may not be able to care for themselves. Therefore, although the list of things evaluated (see below) may seem comprehensive, the level the MSE looks at these things is very limited. There are many different ways to administer this test, so the details below are simply examples of what the test may include.

The MSE looks at:

Level of consciousness: whether the patient is alert, somnolent, stuporous, confused, etc.General appearance: including gait, cleanliness, posture, etc. This can give the evaluating clinician insight into whether the patient is able to do the activities of daily living such as bathing, dressing, grooming, etc.Behavior during the exam: including eye contact, ability to follow commands, appropriateness of responses, mannerisms, etc.Speech/language: is the patient able to speak clearly, fluently, at a speech rate appropriate for the situation, coherently, etc., as well as whether they can read and write (if appropriate for their level of education).Attitude: including whether the patient is cooperative, defensive, easily distracted, interacts in an appropriate manner, etc.Affect: including whether their facial and other expressions are appropriate for the situation and what is being discussed.Mood (as self-reported): including whether they sad, happy, depressed, feeling in control, etc.Orientation: including whether the patient knows who they are, where they are (including state, county, town, hospital name, etc.), when it is (including year, month, day, season, time), and why they are being evaluated.Gross motor function/constructional ability: to test the ability to perform common tasks, for example, possibly tested by asking them to pretend to sew a button on a shirt or to draw the face of a clock that shows a specific time given to them.Attention span/calculation: tested by having the patient do simple calculations (appropriate to their level of education) such as starting at 100 and serially subtracting 7, or spelling the word ‘world’ frontwards and backwards.Intellectual functioning: typically including an assessment of what should be well-known facts such as what is the largest state/city, who won the world series (for baseball fans), and possibly including interpretation of simple proverbs (e.g. what does ‘people who live in glass houses should not throw stones’ mean?).Insight/judgement: this is a very high-level evaluation, such as why are they at the doctor’s office today, or asking them if they found a stamped envelope on the sidewalk what would they do with it, etc.Memory: a high-level assessment often done by giving the patient a string of 5 numbers and asking them to repeat them back (immediate memory) and by telling the patient three objects early in the exam and seeing if they remember them 5-10 minutes later (slightly delayed memory).Thought process: including whether they have racing, tangential, focused, organized, logical, etc. thoughts.Thought content: including a gross evaluation of what is on their mind, whether they have thoughts or see/hear things that are not shared by others, etc.Suicidality/homicidality (as self-reported): including whether they have thoughts of hurting themselves or someone else.

Much more commonly than a full MSE, a mini-MSE is performed. This is a faster, shorter, much more limited version of the full MSE, and it is typically scored on a scale of 0 to 30 with 10 points given for orientation, 3 for thought process, 5 for calculation, 6 for memory, 5 for various language function tests and 1 for constructional ability. From what was released about the test given to evaluate the President, it sounds like it was a mini-MSE that was performed.

So what does it mean if someone has significant abnormalities on the MSE? It could mean the patient has dementia, is unable to competently care for themselves, or, as is most likely, that they need further, more in-depth, testing. On the other hand, what does it mean if someone scores well on a mini-MSE? This would indicate that they do not show obvious signs of dementia, delirium or obvious inability to care for themselves. Any well-functioning adult would be expected to get a good score on a mini-MSE.

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